Among the biggest winners in Tuesday’s elections was President Barack Obama’s signature legislative achievement.

The Affordable Care Act may not be the most popular of laws. In fact, exit polls in several states Tuesday found about half the voters want the sweeping 2010 health care legislation repealed or changed, CNN reported.

But Republican plans to “repeal and replace’’ the law have hit a brick wall. With Democrats keeping control of both the White House and the U.S. Senate, the ACA will remain the law of the land, and the portions of it that have not yet taken effect are on track to do so.

So now, Georgia’s Republican governor and Republican legislative leaders will have two decisions to make, both set up by the health reform law: Will the state expand its Medicaid program? And will Georgia run its own health insurance exchange?

Several states had been waiting for the national election results before making these major health care decisions, Bill Custer, a health insurance expert at Georgia State University, told GHN on Wednesday. The election “is a finish line, but it’s also a starting line,’’ he said.

With the fate of the ACA no longer in doubt, and with deadlines for action growing closer, states will have to pick up the pace on planning related to the law’s provisions, Custer added. “Now the hard work, the detailed work, really begins at the state level.’’

The state’s decision on Medicaid expansion is widely considered the more crucial issue for the state’s health care system. Expansion would add more than 600,000 low-income uninsured adults to the Medicaid rolls, starting in 2014.

Yet the state must make its choice on the exchanges more quickly. The deadline for a state to declare whether it will create its own online insurance marketplace – or let the feds create one – is Nov. 16.
An insurance exchange is envisioned as an online marketplace where individuals and small businesses can shop for affordable coverage.

“It’s probably too late’’ for states not already actively planning a health insurance exchange to have one ready in time, Custer said.

But a state can work with the federal government on how its exchange is set up, then perhaps take it over later, he said.

Ron Bachman, a senior fellow at the Georgia Public Policy Foundation, told the AJC recently that private insurance exchanges should be implemented instead, adding he’s unsure the federal government has enough resources and the capability to run the exchanges.

Uncertainty and discord

A sense of uncertainty surrounds the insurance exchanges, regardless of who runs them.

“Exchanges are a big unknown –- no one knows what it will look like,” said Phaedra Corso, a health policy expert at the University of Georgia’s College of Public Health.

Open enrollment for exchanges would begin next October for a January 2014 start, Corso noted. “Are they really going to be ready?’’ she asked.

Medicaid expansion, meanwhile, will be a contentious issue at the Georgia General Assembly. Though advocates say expansion is a good idea on its own merits, a state can’t be compelled to do it, and some leading Republicans in Georgia and elsewhere flatly oppose the idea.

Gov. Nathan Deal recently said he had no intention of pursuing expansion, calling it too costly to the state.

House Speaker David Ralston, who like Deal is a Republican, praised the governor’s stance, saying, “The costs are enormous, and there is little faith that the federal government will live up to the funding requirements of Obamacare as it stands now,”

A spokesman for Deal has since said that the governor opposes expansion “if the state’s only options remain the ones that are available today,’’ implying that there might be room for compromise.

Under Medicaid expansion as it is now envisioned, the federal government would pay 100 percent of the costs in the first three years, and 90 percent thereafter, with the state picking up the remaining tab.

Deal has backed the idea of a block grant for the Medicaid program, but the Obama administration would likely turn down such a request.

A Deal spokesman could not be reached for comment Wednesday on how the election results affected the governor’s health care agenda.

Still, there may be a middle ground between states rejecting expansion and fully pursuing it, Custer said. Some states have approached the federal government about a partial expansion, up to 100 percent of the federal poverty rate, rather than up to 138 percent ($15,415 for an individual; $26,344 for a family of three in 2012) as currently required.

A partial expansion would still cover a large number of uninsured, Custer said.

While many Georgia legislators are likely to oppose expansion, a coalition of consumer advocates, industry stakeholders and hospitals will push for the state to do it.

Corso of UGA notes that the reform law will remove extra federal funding for hospitals that treat a “disproportionate share’’ of low-income patients. That would be a major problem for safety-net hospitals, such as Grady Memorial Hospital in Atlanta, that rely heavily on this funding.

A decision to expand Medicaid – and the resulting influx of paying patients into these hospitals – might help some hospitals remain financially viable, Custer said.

State Rep. Pat Gardner (D-Atlanta), a health reform supporter, said Wednesday that there is a burgeoning group of advocates and medical providers who see the value of expansion bringing billions of dollars of federal money into the state’s health care system.

Consumer groups will push hard to expand Medicaid.

Cindy Zeldin of the advocacy group Georgians for a Healthy Future cited “the tragic reality that 1.9 million Georgians don’t have health coverage and consequently do not get the care they need to live healthy and productive lives.’’

“I think it will be very hard for Georgia not to do this [expansion],’’ Zeldin said. If the state rejects expanding Medicaid, she said, there will be a negative effect on public health, quality of life and economic development.

Wild cards from Washington

Meanwhile, the federal budget crisis may affect how the ACA plays out here and in other states. Kaiser Health News notes that deficit-reduction talks in Congress, triggered by the Jan. 1 “fiscal cliff” of tax-cut expirations and spending reductions, could change significant parts of the health law. Democrats might agree to cut back on the law’s coverage and subsidies in return for revenue increases or other concessions from Republicans, analysts said, according to the KHN article.

And KHN also noted that while many state-run exchanges may not be ready by 2014, there’s also a potential problem on the federal side. It’s far from certain, KHN said, that the U.S. Department of Health and Human Services – which is supposed to step in and create an exchange if a state does not – will be prepared to do.
Still, Tuesday’s election preserved some popular provisions of the ACA, including the prohibition on insurer exclusions for pre-existing conditions, beginning in 2014.

“It’s huge for people with pre-existing conditions and huge for health care providers,’’ Custer said.

Several provisions of the ACA are good for children and pediatricians, said Dr. Bob Wiskind, president of the Georgia chapter of the American Academy of Pediatrics.
He cited the requirement that children can remain on their parents’ health plan till age 26, and the law’s increased funding to train pediatric subspecialists.

Another key ACA component is a pay increase for physicians who treat Medicaid and PeachCare patients for the next two years, he said. “It could be 20 percent to 30 percent,’’ said Wiskind, an Atlanta pediatrician.

Other major health issues are expected to surface at the General Assembly, including the Medicaid provider tax.

“What is now important is that we truly come to grips with a health care system that is failing and unsustainable on a number of critical fronts, including Medicare and Medicaid,” said Dr. Scott Bohlke, president of the Medical Association of Georgia.

“MAG will be focused on several essential imperatives, which includes preserving physician autonomy, supporting Medicaid reform, promoting tort reform legislation, and relieving the punitive administrative burden that’s been placed on physicians – as well as protecting patient well-being and the patient-physician relationship.”